Problem solving therapy

Use and effectiveness in general practice

Background

Problem solving therapy (PST) is one of the focused psychological strategies supported by Medicare for use by appropriately trained general practitioners.

Objective/s

This article reviews the evidence base for PST and its use in the general practice setting.

Discussion

Problem solving therapy involves patients learning or reactivating problem solving skills. These skills can then be applied to specific life problems associated with psychological and somatic symptoms. Problem solving therapy is suitable for use in general practice for patients experiencing common mental health conditions and has been shown to be as effective in the treatment of depression as antidepressants. Problem solving therapy involves a series of sequential stages. The clinician assists the patient to develop new empowering skills, and then supports them to work through the stages of therapy to determine and implement the solution selected by the patient. Many experienced GPs will identify their own existing problem solving skills. Learning about PST may involve refining and focusing these skills.

Problem solving therapy (PST) – sometimes referred to as ‘structured problem solving’ – is one of the focused psychological strategies (FPS) supported by Medicare under the Better Access Initiative for use by appropriately trained general practitioners. For Medicare purposes, it is referred to as ‘problem solving skills and training’. Problem solving therapy involves patients learning new problem solving skills or reactivating previously learned ones. These skills can then be applied to specific life problems that are associated with psychological and somatic symptoms. The clinician’s role is to facilitate and support this skill development. Skills can be applied to a range of life difficulties, including relationship conflict. Once these skills have been developed, patients may find them useful to apply to future problems.

Problem solving therapy has been described as pragmatic, effective and easy to learn. It is an approach that makes sense to patients and professionals, does not require years of training and is effective in primary care settings.1 It has been described as well suited to general practice and may be undertaken during 15–30 minute consultations.2

Initially, the techniques of social problem solving emerged in response to empirical observations including that people experiencing depression exhibit a reduced capacity to resolve personal and social problems.4,5 Problem solving therapy specifically for use in primary care was then developed.6

Problem solving therapy has been shown to be effective for many common mental health conditions seen by GPs, including depression7–9 and anxiety.10,11 Most research has focused on depression. In randomised controlled trials, when delivered by appropriately trained GPs to patients experiencing major depression, PST has been shown to be more effective than placebo and equally as effective as antidepressant medication (both tricyclics and selective serotonin reuptake inhibitors [SSRIs]).7,8 A recent meta-analysis of 22 studies reported that for depression, PST was as effective as medication and other psychosocial therapies, and more effective than no treatment.9 For patients experiencing anxiety, benefit from PST is less well established. It has been suggested it is most effective with selected patients experiencing more severe symptoms who have not benefited from usual GP care.10 Problem solving therapy may also assist a group of patients often seen by GPs: those who feel overwhelmed by multiple problems but who have not yet developed a specific diagnosis.

Although PST has been shown to be beneficial for many patients experiencing depression, debate continues about the mechanism(s) through which the observed positive impact of PST on patient affect is achieved. Two mechanisms have been proposed: the patient improves because they achieve problem resolution, or they improve because of a sense of empowerment gained from PST skill development.12 Perhaps both factors play a part in achieving the benefits of PST as a therapeutic intervention. The observed benefit of PST for patients experiencing anxiety may be due to problem resolution and consequent reduction in distress from anticipatory concern about the identified but unsolved problem.

It is important to note that, while in the clinical setting we may find ourselves attempting to solve problems for patients and to advise them on what we think they should do,13 this is not PST. Essential to PST, as an evidence based therapeutic approach, is that the clinician helps the patient to become empowered to learn to solve problems for themselves. The GP's role is to work through the stages of PST in a structured, sequential way to determine and to implement the solution selected by the patient. These stages have been described previously.14 Key features of PST are summarised in Table 1.

Table 1. Stages of problem solving therapy

The GP/therapist introduces the concept of PST and its stages

The patient identifies the problem to be addressed. The GP may ask questions to clarify the nature of the problem

The patient determines the goal they want to achieve

The patient brainstorms possible solutions to the problem that have the potential to achieve their goal

The patient is encouraged to consider the pros and cons of potential solutions and choose their own solution

The patient implements their solution

The outcome is reviewed with the GP and the patient considers further action if needed. The patient may progress to address further problems in this way

Using PST in general practice

Using PST, like any other treatment approach, depends on identifying patients for whom it may be useful. Patients experiencing a symptom relating to life difficulties, including relationship, financial or employment problems, which are seen by the patient in a realistic way, may be suitable for PST. Frequently, such patients feel overwhelmed and at times confused by these difficulties. Encouraging the patient to clearly define the problem(s) and deal with one problem at a time can be helpful. To this end, a number of worksheets have been developed. A simple, single page worksheet is shown in Figure 1. A typical case study in which PST may be useful is presented in Table 2. By contrast, patients whose thinking is typically characterised by unhelpful negative thought patterns about themself or their world may more readily benefit from cognitive strategies that challenge unhelpful negative thought patterns (such as cognitive behaviour therapy [CBT]).15 Some problems not associated with an identifiable implementable solution, including existential questions related to life meaning and purpose, may not be suitable for PST. Identification of supportive and coping strategies along with, if appropriate, work around reframing the question may be more suitable for such patients.

Problem solving therapy may be used with patients experiencing depression who are also on antidepressant medication. It may be initiated with medication or added to existing pharmacotherapy. Intuitively, we might expect enhanced outcomes from combined PST and pharmacotherapy. However, research suggests this does not occur, with PST alone, medication alone and a combination of PST and medication each resulting in a similar patient outcomes.8 In addition to GPs, PST may be provided by a range of health professionals, most commonly psychologists. General practitioners may find they have a role in reinforcing PST skills with patients who developed their skills with a psychologist, especially if all Better Access Initiative sessions with the psychologist have been utilised.

The intuitive nature of PST means its use in practice is often straightforward. However, this is not always the case. Common difficulties using PST with patients and potential solutions to these difficulties have previously been discussed by the author14 and are summarised in Table 3. Problem solving therapy may also have a role in supporting marginalised patients such as those experiencing major social disadvantage due to the postulated mechanism of action of empowerment of patients to address symptoms relating to life problems.12 of action includes empowerment of patients to address symptom causing life problems. Social and cultural context should be considered when using PST with patients, including conceptualisation of a problem, its significance to the patient and potential solutions.

General practitioners may be concerned that consultations that include PST will take too much time.13 However, Australian research suggests this fear may not be justified with many GPs being able to provide PST to a simulated patient with a typical presentation of depression in 20 minutes.15 Therefore, the concern over consultation duration may be more linked to established patterns of practice than the use of PST. Problem solving therapy may add an increased degree of structure to complex consultations that may limit, rather than extend, consultation duration.

Figure 1. Problem solving therapy patient worksheet

Table 2. Case study

Caroline, a school integration aide, is a single parent of four girls aged 13 to 22 years. She presents with tiredness, sadness and loss of interest in both her job and her friends. Her DASS21 score supports the diagnosis of mild/moderate depression. After discussing treatment options she decides to try PST. You help her explore the life problems that are distressing her and she identifies three:

her aged mother who insists on living on her own despite being approved for supported care

her daughter (Anne, aged 22 years), who has not spoken to her for 3 years

her job insecurity as a single parent and provider for three adolescent children.

She describes feeling overwhelmed by these problems and the sense that there are no solutions. She decides to start with concerns about Anne and focus on their lack of contact, which followed conflict 3 years ago when Anne abruptly left home. As Caroline talks through the problem she is able to clarify the major problem as a concern regarding Anne’s safety as she does not trust her daughter’s partner. While she would like the relationship restored, she identifies her goal as finding out if Anne is okay. She brainstorms a number of ways to achieve her goal. These include contact through one of Anne’s sisters and sending a personal birthday card including an invitation to meet for coffee

Caroline decides to send a special birthday card. She feels empowered experiencing a sense of being able to do something to address one of her problems. Follow up in 10 days is arranged to assess outcomes including her affect and to further reinforce problem solving skills

Problem(s) are complex and the patient feels they don’t know where to start

The patient can break the problem(s) into a number of smaller problems that they might find easier to conceptualise

Difficulty is not a problem to be solved but a unhelpful thinking pattern

Use different cognitive interventions such as CBT (cognitive restructuring)

Goal(s) unclear

Avoid moving directly from problem identification to solutions, ‘missing’ goal setting through enthusiasm to get the problem solved

The patient is unable to suggest any solutions (brainstorming)

Use probe questions to help the patient consider potential solutions

The patient’s solution is unrealistic and unlikely to succeed

Use questions to help the patient recognise this difficulty

The patient plan is vague

Encourage the patient to develop as much detail about the plan as possible

PST skill development for GPs

Many experienced GPs have intuitively developed valuable problem solving skills. Learning about PST for such GPs often involves refining and focusing those skills rather than learning a new skill from scratch.13 A number of practical journal articles16 and textbooks10 that focus on developing PST skills in primary care are available. In addition, PST has been included in some interactive mental health continuing medical education for GPs.17 This form of learning has the advantage of developing skills alongside other GPs.

Summary

Problem solving therapy is one of the Medicare supported FPS available to GPs. It is an approach that has developed from a firm theoretical basis and includes principles that will be familiar to many GPs. It can be used within the constraints of routine general practice and has been shown, when provided by appropriately skilled GPs, to be as effective as antidepressant medication for major depression. It offers an additional therapeutic option to patients experiencing a number of the common mental health conditions seen in general practice, including depression7–9 and anxiety.10,11

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